For diagnostic services, there is no income eligibility required. For treatment services, families must meet CMH income guidelines.
Emergency room services are only covered if they are related to the eligible medical conditions, are provided at a CMH designated hospital, and are listed on the Letter of Approval.
No. CMH does not pay for in-home nursing services.
CMH does not cover:
· primary care, this means CMH will not pay for well child visits or for short term conditions like the common cold, or
· mental health conditions such as obsessive-compulsive disorder or behavioral conditions, or
· experimental treatments or procedures.
No. CMH will cover a diagnostic workup for children to determine a diagnosis of autism. However, CMH does not pay for any treatment services.
The CMH providers, listed by county, are available. Click HERE and find your county. Under each count you will find: Equipment, Facilities, Pharmacies or Practitioners. If a category is not listed it is because that service is not offered at a CMH approved provider in that county.
Note: Each category is listed alphabetically, first by specialty, then by last name.
How to Enroll
The Children with Medical Handicaps Program (CMH) provides assistance to families who have children with special health care needs who meet the medical and financial eligibility criteria. All criteria are for children under the age of 21 who have special health care needs and are residents of the State of Ohio.
In order to enroll in CMH, a Medical Application Form must be submitted by a CMH-approved physician. Local health department public health nurses can provide a referral to start the enrollment process. Dependent upon the program, financial eligibility may or may not be a criteria.
Medical Eligibility Criteria
For the CMH Diagnostic Program, a child must:
- Be under the age of 21
- Be a permanent resident of Ohio
- Be under the care of a CMH-approved doctor (MD or DO)
- Have a possible special health care need
For the CMH Treatment Program, a child must:
- Be under the age of 21
- Be a permanent resident of Ohio
- Be under the care of a CMH approved doctor (MD or DO)
- Be financially eligible
- Have an eligible special health care need
For the Service Coordination Program, a child must:
- Be under the age of 21
- Be a permanent resident of Ohio
- Be under the care of a CMH-approved hospital specialty team approved for service coordination
- Have a diagnosis eligible for service coordination
Financial Eligibility Criteria
The CMH Treatment Program has a financial eligibility requirement.
Financial eligibility for CMH is determined case by case based on:
- A percentage of the federal poverty income guidelines
- The family’s taxable income
- The medical care the child needs
- A calculation of the family’s maximum ability to pay for health care
- Amount spent on private health insurance
- Amount spent on weekly child care
CMH does not count personal assets such as a home, car or savings account when determining financial eligibility. Also, income from child support, stepparent income or social security income (SSI) for the child is not counted.
When a child’s doctor applies to CMH for treatment services a child needs, CMH will send the parent or legal guardian a financial application packet unless the child is active on the Medicaid program. It is important that all the instructions in the packet are followed. A form called the CMH FInancial Application will be in the packet. It must be filled out and mailed to CMH along with 3 pay stubs from each parent/adult client who is employed and a copy of their most recent federal income tax form (1040) and verification of child care expenses. A child receiving benefits through Medicaid, SSI or WIC is automatically financially eligible for CMH treatment services, regardless of the parent’s income.
CMH and Medicaid
Families who meet the income standards for the Medicaid program of the Ohio Department of Medicaid (ODM) will be required to apply to that program for coverage of medical services for their child. The Medicaid Guidelines are in the CMH financial application packet, along with instructions on how to apply. If over-income for the Medicaid Program, the CMH Financial Application, denial letter from Healthy Start and income verifications must be sent to CMH to determine eligibility for CMH.
If a Family is Determined to be “Over Income” for the CMH Program
If CMH sends the family a denial letter, stating they are “over-income” for the Treatment Program, they will also receive information about the CMH’s cost share program. They will be given a cost share dollar amount and CMH Information Sheet: Steps to Meet your Cost Share on how they can meet that cost share amount. When the family provides proof to CMH that they have spent that amount of money on medical costs including dental, and/or vision bills for any member of their family, they will have met their cost share. On the date the cost share is met, the child will become eligible for the Treatment Program for one year.
Yes. However, CMH will request a copy of the pre-existing clause.
CMH provides services for children with special health care needs. Many of these children have medical conditions that require ongoing treatments. Some examples of these conditions are diabetes, heart defects, chronic lung disease, cancer and hearing loss. CMH may be able to cover services that are not covered by insurance and/or Medicaid.
In some cases, yes. If the claim was rejected for reasons such as: deductible not met, non covered benefit, policy not in effect, terminated or benefits exhausted, or is pre-existing, CMH will process the claim. There are also some reasons CMH will not process claims for payment.
Yes. Providers must bill other insurance before CMH. Medicaid pays for services such as medical care not related to the eligible diagnosis. You will need to show your insurance card or give the provider these details: Children With Medical Handicaps will also need this FORM filled out and sent in with your other documents.
· Policy & Group Numbers
· Name of Employer
· Social Security Number of Policyholder
Transition to adult life is a process of planning for the future needs of the youth with special health care needs. Transition planning should ideally begin before the age of 14 years. The transition plan should provide the youth with the tools and resources to prepare them for adulthood and to address medical, employment/education and independence issues. Many times, transition planning is very stressful for families, but the stress can be eased with early planning and discussions with professionals who can assist with the plan. The plan should be written down and reviewed at least every six months. Physicians, hospital-based service coordinators and local public health nurses have expertise to assist and guide the family through the transition process.
When your teen turns 18 years of age, they are considered an adult under Ohio law.
Your son or daughter:
· Will be required to sign the CMH Release of Information and Consent form, except if you are your child’s legal guardian. This document will be sent to the child prior to their 18th birthday.
· Must give consent for CMH to discuss their case with anyone, including their parents. The only exception would be if the child has an appointed legal guardian. CMH must be provided a copy of the legal document identifying the legal guardian.
More information on transition can be found at:
Adapted with permission from The Michigan Department of Community Health: Transition Resource Manual http://www.michigan.gov/mdch
No. Providers, including pharmacies, should bill the appropriate payer resource (Medicaid/Insurance/CMH) first. The Ohio Revised Code section 3701.023 prohibits providers from billing or charging CMH families for co-pays or deductibles. You should contact the CMH third-party unit for assistance at 1-800-755-4769 or 1-644-466-1700.
The Children with Medical Handicaps Program (CMH) promotes and supports the medical home concept for children with special health care needs.
A medical home is a way to provide high quality health care that is:
· Family centered
· Culturally competent
Most importantly, a medical home is a partnership between the doctor and the child’s family. CMH works with doctors and other health care providers to ensure every child with a special health care needs will have a medical home.
The CMH Financial Application form is needed to fully process your application. It is included in the financial application packet sent to you when your child’s doctor applies for CMH treatment services for your child. The parent/guardian with legal custody should complete the CPA.
If the client has Medicaid you will NOT have to fill out the financial application. All other clients who wish to participate in the "Treatment Program" will need to fill out the CMH Financial Application.
The Children with Medical Handicaps Program (CMH) has three core programs for children with special health care needs:
· Service coordination
Each program requires medical and/or financial criteria to be met before a child/adult can be eligible to receive CMH services.
· Adult Cystic Fibrosis Program: This program provides limited treatment services for persons over age 21 with cystic fibrosis. Financial eligibility is required. The benefit package currently consists of prescription medications, medical supplies, special formula, and public health nursing visits upon request.
· Adult Hemophilia Insurance Premium Program (HIPP): HIPP helps with payment of health insurance premiums for persons over 21 years of age, with hemophilia or a related bleeding disorder, who meet the eligibility criteria as defined in Ohio Administrative Code 3701-43-16.1.
· Metabolic Formula Program: This program provides metabolic formula to individuals with phenylketonuria (PKU), homocystinuria and other metabolic disorders. Without special formula, individuals, especially infants and children, may develop brain damage and mental retardation.
· Community Nutrition Services: Children on the CMH diagnostic or treatment programs who have a nutrition-related concern may request to work with a CMH community dietitian. Community dietitians are registered and licensed dietitians with additional training in pediatrics. They work with the family during home visits to provide nutrition assessments and education. Some examples of issues community dietitians can help with include evaluation of tube feedings, treatment for food allergies, strategies for gaining or losing weight, or any feeding behaviors that cause a caregiver concern. To find a community dietitian in your area, contact (614) 466-1700.
· Premium Payment Assistance Program: Families who are using a COBRA option or who are paying annual health insurance premiums that are equal to or greater than 2.5 percent of their adjusted gross annual income and whose child is enrolled in the CMH treatment program may be eligible for this program. For CMH to enroll a family, it must prove to be cost effective for CMH. Families often are referred to this program by public health nurses or hospital staff.
· Public Health Nursing Services: Public health nursing services are approved for every child in the CMH diagnostic, treatment and service coordination programs. A public health nurse is: a registered nurse employed by the local health department; skilled in working with children, families and medical/dental providers; and an expert in accessing local community agencies to help families.
CMH will become the primary payer for services. You may want to elect COBRA benefits. COBRA must be elected within 60 days after written notice of termination is received. CMH can assist with the cost of the premiums.
If the insurance network allows you to use non-network providers and will reimburse at a lesser rate, CMH can be billed for the balance of the provider bill. If the insurance plan does not allow you to use non-network providers, and you choose to do so, CMH may not authorize payment for those charges.
No. You should notify CMH if you are approved for Supplemental Security Income (SSI) or Medicaid.